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CROSSWORKS

Notice of Privacy Practices

CROSSWORKS

Notice of Privacy Practices

This notice describes how your medical information may be used and disclosed (provided to others) and how you can get access to this information. Please review this notice carefully.

This Notice of Privacy Practices explains how Crossworks may use and provide your Protected Health Information (called PHI) to others for treatment, payment, and health care “operations” as described below, and for other purposes allowed or required by law.

I. OUR RESPONSIBILITIES:

Crossworks takes the privacy of your child’s (your) health information seriously. We are required by law to keep your health information private and provide you with this Notice of Privacy Practices. We will act according to the terms of this Notice. We reserve the right to change this Notice of Privacy Practices and to make any new practices effective for all Protected Health Information that we keep. Any changes made to the Notice of Privacy Practices will be posted in the member area, posted on our Web site www.crossworks.mo.me/ and given to you at your next appointment.

II. WHAT IS “PROTECTED HEALTH INFORMATION” (PHI)?

Protected Health Information (PHI) is information about a patient’s age, race, sex, and other personal health information that may identify the patient. The information relates to the patient’s physical or mental health in the past, present, or future, and to the care, treatment, and services needed by a patient because of his or her health.

III. HOW IS MEDICAL INFORMATION USED?

Crossworks uses medical records to record health information, to plan care and treatment.. For example, your insurance company may need us to give them procedure and diagnosis information to bill for patient treatment we provide. Other health care providers or health plans reviewing your records must follow the same privacy laws and rules that Crossworks is required to follow.

Patient records also greatly help our researchers find the best possible treatment. All Crossworks researchers must follow the same rules and laws that other health care providers have to follow to keep patient information private. Details that may identify patients will not be disclosed for research purposes to anyone outside of Crossworks without written permission from the patient or the patient’s parent or legal guardian.

V. EXAMPLES OF HOW MEDICAL INFORMATION MAY BE USED FOR TREATMENT, PAYMENT, OR HEALTH CARE OPERATIONS

·Medical information may be used to show that a patient needs certain care, treatment, and services (such as lab tests, prescriptions, treatment plans, and research study requirements).

·We may send claims to your insurance company containing medical information. We might also contact their utilization review department to receive precertification (approval for treatment in advance).

·We may use the emergency contact information you gave us to contact you if the address we have on record is no longer correct.

·We may contact you to remind you of the patient’s appointment by calling you or mailing a postcard.

·We may contact you to discuss other possible treatments or benefits related to health that might interest you.

·Before any more information is given to affiliate, schools or other agencies you will be asked to sign another consent document known as an Authorization Form.

VI. WHY DO I HAVE TO SIGN A CONSENT FORM?

When you sign the Consent for Release of Information, you are giving Crossworks permission to use and disclose (provide to others) Protected Health Information for treatment, payment, and health care operations, as described above. This permission does not include psychotherapy notes (defined in Section VII below), psychosocial information (defined in Section VIII below), alcoholism and drug abuse treatment records, and other privileged categories of information, all of which require a separate permission. You will need to sign a separate consent form to have Protected Health Information given out for any reason other than treatment, payment, or health care operations or as required or permitted by law.

VII. WHAT ARE PSYCHOTHERAPY NOTES?

Psychotherapy notes are notes recorded (in any form) by a mental health professional for the purpose of studying a conversation that took place during a private counseling session. This session can be with a single person, a group, or a family. Conversation notes from a counseling session are separated from the rest of the patient’s medical record. Psychotherapy notes do not include: notes about which medicines you are taking or how those medicines affect you; the start and stop times of counseling sessions; the types of treatment you are given; how often treatments are given; the results of clinical tests; and any summary of the following items: diagnosis, functional state, the treatment plan, symptoms, expected outcome, and progress to date.

VIII. WHAT IS PSYCHOSOCIAL INFORMATION?

Psychosocial information is information about your family’s social history and counseling services you have received.

IX. WHY DO I HAVE TO SIGN A SEPARATE PERMISSION FORM?

To provide patient Protected Health Information to other people for any reason other than treatment, payment, and health care operations (described above) or as required or permitted by law, we must have a permission form known as an Authorization Form signed by the patient or the patient’s parent or legal guardian. This form clearly explains how they wish the information to be used and disclosed. The following are some examples of information that require separate permission before we can release it:

·Psychotherapy notes

·Information and photographs for public relations activities.

·Information shared with other agencies such as hospitals, schools, doctors for quality of care treatment.

X. CAN I CHANGE MY MIND AND WITHDRAW PERMISSION FOR Crossworks TO DISCLOSEI?

You may change your mind and withdraw (revoke) permission, but we cannot take back information that has been released up to that point. Permission cannot be withdrawn if (1) the information is needed to maintain the integrity of the research study, or (2) if the permission was originally given to obtain insurance coverage. All requests to withdraw permission for uses and disclosures of information should be made in writing.

XIV. WHEN IS MY CONSENT NOT REQUIRED?

The law requires that some information may be disclosed without your permission during the following times:

·In an emergency

·When communication or language is very limited

·When required by law

·When there are risks to public health

·To conduct health oversight activities

·To report suspected child abuse or neglect

·To certain government agencies who monitor activity

·In connection with court or government cases

·For law enforcement purposes

·If health or safety is seriously threatened

XV. YOUR PRIVACY RIGHTS

The following explains your rights with respect to your Protected Health Information (called PHI) and a short description of how you may use these rights.

1. You have the right to review and to ask for a copy of your health information.

This means that except as explained below, you may review and get a copy of your PHI that is contained in a “designated record set” as long as we keep the PHI. A designated record set contains medical and billing records and any other records that Crossworks uses to make decisions about your child’s (your) health care. You may not read or be given a copy of psychotherapy notes; information collected for use in a civil, criminal, or administrative action, or court case; and certain PHI that is protected by law. In some situations, you may have the right to have this decision reviewed. Please ask if you have questions about access to your child’s (your) medical record.

If needed and at your request, Crossworks may provide an electronic copy of your child’s (your) record if Crosswroks is able to do so. A fee will be charged for requesting a copy of your health or medical records.

2. You have the right to request that access to your health information be limited.

This means you may ask us to restrict or limit disclose for treatment, payment, or health care operations. We will tell you if we reject your request. If we do agree to the requested restriction, we will not violate that restriction unless it must be violated to provide emergency treatment. You may request a restriction by contacting the St. Jude Privacy Officer.

3. You have the right to request to receive private communications in another way or at other locations.

We will agree to reasonable requests. To carry out the request, we may also ask you for another address or another way to contact you, for example, mailing to a post office box. We will not ask you to explain why you are making the request. Requests must be made in writing.

4. You have the right to request changes to your health information.

Requests must be made in writing.

5. You have the right to receive a record of when your health information has been disclosed by CROSSWORKS.

You have the right to request a record (accounting) of when Crossworks has disclosed your PHI. This right applies to any time Crossworks discloses your PHI for purposes other than treatment, payment, or health care operations as described in this Privacy Notice. We are not required to account for information releases: that you requested, that you agreed to by signing an Authorization Form: Requests for records about Crossworks disclosures of your PHI may not be made for time periods of more than six (6) years or it could be an earlier time period depending upon what the law requires.

6. You have the right to receive a paper copy of this Notice of Privacy Practices.